Meera Vashisht: Native American Motherhood— Mortality, Societal Indifference, and Unnecessary Suffering
It is time that the fatal repercussions of biases from our nation’s health care providers against Native Americans and other ethnic minorities is better scrutinized. Native American women have the highest maternal mortality rate of any ethnic group living in the United States. Indigenous women are approximately three times as likely as White women to die of pregnancy-related causes, and hemorrhage and hypertensive disorders during the gestational period are among the biggest contributors1. According to the CDC, sixty percent of maternal deaths are preventable, and it is well overdue to implement greater preventive efforts, including funding more and better research, as well as responding to factors that contribute to these disproportionate maternal mortality rates2, 3. This study deals with institutional racism within the US health care sector and its impact on Native American women during and after childbirth, as well as the related social determinants of health, social injustice, and structural racism that continues to permeate within this community .
Native American women residing on reservations and tribal lands need better access to affordable housing and transportation. This is to properly access safe childbirth through the Indian Health Service clinics and other designated facilities and hospitals, as well as greater access to both justice and health care systems that work with those victimized by these critical ongoing issues. Furthermore, there is a pervasive neglect for addressing the standards of living and care for Native women, which collectively contributes to maternal mortality rates. Our current system needs to better evaluate, regulate, and scrutinize the reasons any unnecessary health risks exist in the first place, and it is our society’s responsibility to address systemic issues hindering Native women’s health. Non-Native doctors and health care providers must be better educated on the cultural considerations necessary to assist Native American women, and it is incumbent on the designated government agencies to help reduce the stress factors contributing to these unnecessary mortality rates.
There is a marked and continued lack of governmental funding pertaining to any efforts of tracking or addressing the very issues contributing to disproportionately higher rates of Native American maternal deaths, as well as a complete lack of support for traditional birthing practices supporting the reproductive health of Native women. In response to these concerns, policymakers and relevant stakeholders should be funding and developing programs that are informed by a more comprehensive understanding of living conditions and resources for Native American women through ongoing consultation with tribes. Perhaps more relevant, though, traditional Native birthing practices and better cultural competencies in health care settings also need to be re-introduced and utilized. All these measures would further ensure that the health care standards and resources for Native American women are congruent with basic national standards.
Barriers to pre and postnatal care are also present. One pressing issue is the location of many reservations, coupled with lack of adequate transport. During a check of Pregnancy and Risk Assessment and Monitoring System Data, 27% of Native American mothers polled reported not having access to transportation needed for pre-natal appointments, while other Indigenous women within the US Department of Health and Human Services Maternal and Child Health Project Launch Program said they had limited possibilities to get to medical checkups and appointments, an essential component to having a healthy delivery and child4.
Not surprisingly, the lowest healthcare outcomes for pregnant Indigenous women are those living in areas with lower household incomes and the highest Native American populations in the US. These are also areas with higher Medicaid populations, and in order to gain access to Medicaid, Native American women also need access to cars, phones, and the internet5.When Native mothers gain access to Medicaid later into their pregnancy, their delay in obtaining insurance can be perceived as “non-compliance,” or a perceived risk around drug use by medical professionals6. Moreover, structural racism and cultural competency by providers also plays a role in limiting the trust established between patient and caregiver. It should be pointed out that Native American women are regularly administered drug tests by non-Native health professionals due to racial stereotyping7.
Indigenous women can often feel stigmatized, stereotyped, and dismissed by the Western medical system, which in turn makes many patients hesitant about accessing necessary healthcare in the first place. For example, Native mothers may avoid seeking maternal healthcare because their provider holds assumptions and biases about Indigenous people and acts in a prejudicial or discriminatory manner. Moreover, Native mothers face additional health repercussions related to the social injustices they face because these very factors also cause chronic stress and anxiety, and these same stressors have been shown to increase maternal cortisol levels, potentially causing preterm labor or even altering a newborn’s brain development and immune system8. Without question, Native mothers experience a disproportionate amount of trauma, such as high rates of addiction, suicide, and mental illness, which impacts not only their own health but that of their babies. It can also lead to intergenerational trauma, and what is important to note here is that trauma impacts the brain development of a fetus that has effects on a genetic level. Trauma is also a root cause of morbidity and mortality9.
Native American infants are nearly twice as likely to die before their first birthday as White infants. Congenital malformations, sudden infant death syndrome, and prematurity are among the main causes of mortality, and these rates have remained constant over the last two decades. The Native American demographic was the only US group that did not experience a decline in infant deaths10. Furthermore, a standard practice of the CDC is to only report maternal race when it is being assigned to an infant, excluding infants with Native paternity from birth data. Worse still, coroners are often left to report the deceased’s race on death certificates, frequently misreporting them as belonging to other ethnic groups. As a result, infant and maternal mortalities are undercounted11.
Indigenous Americans make up approximately 2% of the US population, causing this demographic to be overlooked and ignored in public health analyses. Because the sample size is limited, Native Americans are almost always dropped from government reports12. There is still extremely limited data and research concerning Native maternal and infant mortality and existing evidence shows some congruence with other underserved groups. Moreover, Native medical records concerning birth and death certificates often contain racial misclassifications, and the medical research that does exist tends to focus on the role of healthcare and not on patient concerns13.
The main contributors of Native American pregnancy-related maternal mortality are cardiomyopathies, hypertensive issues surrounding the gestational period, and hemorrhage. When these are compounded by the existing medical issues that most Native Americans face, like obesity caused by Western diets, diabetes, and blood transfusions, the situation becomes especially dire14. Social issues facing Natives are also contributors to maternal mortality among Native women. Substance abuse, severe poverty, suicide, and high crime rates are also factors, but with limited data of what is causing maternal mortality among Native women, it becomes especially difficult to comprehend the true incidence and prevalence15.
It goes without saying that policy initiatives are long overdue in providing the necessary funding for health-related services to Native American women. Desperately needed are the necessary research initiatives to fully understand the full extent Native American mothers face within a westernized healthcare system. If this does not happen, we may never know the true extent of Native American mortality numbers surrounding pregnancy and childbirth, and it is clear that the health care system Natives are faced with continues to be fragmented and decentralized. Moreover, there is a desperate need for internal and external leadership to help solve these issues. Native American women are faced with an ongoing health crisis that continues to be ignored, and is merely reflective of the significant health disparities that continue to exist between the Native American populace and the other demographics living within the US. Better collaboration between federal, state, tribal, and healthcare providers needs to immediately be implemented to help eradicate the unnecessary deaths of Native women during and after childbirth.
Meera Vashisht is a Sophomore at Yale University in Ezra Stiles College
Citations
1.) Petersen EE, Davis NL, Goodman D, Cox S, Mayes N, Johnston E, et al. Vital signs: pregnancy-related deaths, United States, 2011–2015, and strategies for prevention, 13 states, 2013–2017. MMWR Morbidity Mortality Weekly Rep 2019; 68: 423–429.
2.) Centers for Disease Control, Pregnancy Mortality Surveillance System, Centers for Disease Control and Prevention, https://www.cdc.gov/reproductivehealth/maternal-mortality/pregnancy-mortality-surveillance-system.htm
3.) Stephanie Big Crow, MD, Written Statement for the December Briefing before the South Dakota Advisory Committee to the U.S. Commission on Civil Rights, Dec. 16, 2020.
4.) Centers for Disease Control and Prevention, Cultural Competence in Health and Human Services, (n.d.), https://npin.cdc.gov/pages/cultural-competence#what
5.) Dominguez, A., Appanaitis, I., Simpson, S., Yang, A., Lind, M. (2016, October). Community Health Profile: National Aggregate of Urban Indian Health Program Service Areas. Retrieved 7 June 2019 from Urban Indian Health Institute website: http://www.uihi.org/wp-content/uploads/2017/08/UIHI_CHP_2016_Electronic_20170825.pdf
6.) Warne, D., Frizzell, L.B. (2014). American Indian Health Policy: Historical Trends and contemporary Issues. American Journal of Public Health, 104(3), 263-267.
7.) National Partnership for Women and Families (2019). Tackling Maternal Health Disparities: A Look at Four Local Organizations with Innovative Approaches. Retrieved 7 June 2019, from http://www.nationalpartnership.org/our-work/resources/health[1]care/maternity/tackling-maternal-health-disparities-a-look-at-four-local-organizations-with-innovative-approaches.pdf
8.) Arambula Solomon, T.G., Cordova, F.M., Garcia, F. (2017, March). What’s Killing Our Children? Child and Infant Mortality among American Indians and Alaska Natives. National Academy of Medicine; Chalouhi, S.E., Tarutis, J., Barros, G., Starke, R.M., Mozurkewich, E.L. (2015, December). Risk of postpartum hemorrhage among Native American women. International Journal of Gynaecology and Obstetrics, 131(3), 269-272.
9.) National Partnership for Women and Families. (2019, April). American Indian and Alaska Native Women Face Pervasive disparities in Access to Health Insurance from http://www.nationalpartnership.org/our-work/resources/health-care/AIAN-health-insurance-coverage.pdf
10.) Dominguez, A., Appanaitis, I., Simpson, S., Yang, A., Lind, M. (2016, October). Community Health Profile: National Aggregate of Urban Indian Health Program Service Areas from Urban Indian Health Institute website: http://www.uihi.org/wp-content/uploads/2017/08/UIHI_CHP_2016_Electronic_20170825.pdf
11.) Fredericks L., Hodge F. Traditional approaches to health care among American Indians and Alaska Natives from Huff R. Kline M. Promoting health in multicultural populations. Sage, Thousand Oaks, CA 1999: 313-362
12.) Rhoades D. Racial misclassification and disparities in cardiovascular disease among American Indians and Alaska Natives. Circulation. 2005; 111:1250–1256.
13.) Epstein M, Moreno R, Bacchetti P. The underreporting of deaths of American Indian children in California, 1979 through 1993. Am J Public Health.1997; 87:1363–1366.
14.) Adjusting for Miscoding of Indian Race on State Death Certificates. Washington, DC: Indian Health Service; 1996.
15.) Stehr-Green P, Bettles J, Robertson LD. Effect of racial/ethnic misclassification of American Indians and Alaskan Natives on Washington State death certificates, 1989–1997. Am J Public Health. 2002; 92: 443–444.
